Protecting the “blind side”

For those who watch professional football, there is nothing worse than seeing your team’s quarterback blindsided. A quarterback, for those who do not watch football, is the guy who takes the ball from the center and either hands it off to someone else, runs it himself, or passes it to a person down the field. He does this with about 1500 pounds of collective humanity chasing him. Quarterbacks tend to be runty by comparison (Johnny “Mr Football” Manziel, it turns out, is under 6 feet tall and weighs 207 in gym shorts) and when turned to their dominant side cannot see people coming from their other (blind) side. If two 300-pounders meet at the quarterback they can turn a hundred million dollar investment into just another confused short person, especially if the quarterback isn’t expecting it.

Football teams learned that having a good quarterback was good, and good protection was better. Left tackles, the 300-pound dudes who keep the other guys’ 300 pound dudes off the quarterback, have quietly become among the highest paid ball players in the NFL, second only to the quarterbacks. Part of the reason is that the number of 300-pound men who can run fast, have tremendous peripheral vision, are smart enough to understand an NFL playbook, and can fight off other 300-pound men are few . The other part of the reason is that without one of those dudes, you are paying a confused short person a lot of money to run for his life in front of a lot of empty seats. It wasn’t until players renegotiated the collective bargaining contract and lineman were able to become free agents that the true value of a great left tackle (for a right handed quarterback) was realized.

As Uwe Rheinhart discussed several years back, we have yet to learn the value of left tackles in American medicine. Every medical student wants to be the star who gets to brag about the robotic surgery success in the doctor’s locker room after the game and collect the star’s paycheck (an consequence of our current payment system). Fewer want to be the primary care doctor, who facilitates collaboration, engages in probing conversations with patients, and takes the myriad of small steps that avoid medical errors. The primary care doctors, the left tackles of medicine, were left behind by the payment structure.

What free agency did for fast, smart, 300-pound guys, health reform might do for primary care. By paying less for bad care (readmissions, excess test utilization) and more for good care (satisfied patients, meeting benchmarks for chronic illness care) Medicare might add value to the primary care visit. While primary care docs will likely never generate over $200 an hour in a fee-for-service world like our surgical and radiologist colleagues do, in the future we will add value to their care by reducing bad care and improving care within the system. By holding the system accountable, everyone working as a team will allow effective care delivery to happen. For some now, for others of us in the near future, more money will flow into systems that deliver better care.

Of course, as a healthcare left tackle, this may just be my fantasy. Some think that left tackles are over-rated. Perhaps we can have the line count 1001, 1002, 1003, 1004, 1005 before they run in. Then everyone could be a quarterback.

2 comments

As a fellow left tackle I’m encouraged by BC/BS of Alabama new quality rewards for PCMH , PQRS compliance and board certification. The growth and development of ACO’s will be our next challenge for reimbursement .

The free agent analogy best fits Direct Primary Care where the primary care physician, tired of being compromised by payment design, goes direct to the patient.

The needs of Alabama populations left behind, 60 million Rural Americans, 200 million Americans located in zip codes, and 90 million in counties lowest in physician concentrations are not served well by

1. Direct Primary Care, Concierge Care, Collaborative Care, pay for performance, or value based designs which are great for care of populations already being served but penalize providers caring for populations in most need of care
2. Internal medicine primary care or adult medicine NP
3. Pediatric primary care or pediatric NP
4. Geriatric or women’s health training for MD, DO, NP, or PA
5. Most medical schools
6. International medical school graduates except from schools in the Philippines, Nigeria, and Central America

The health services, health access, and economic needs of Americans most in need of care are not met by grocery store low margins of primary care revenue over costs – resulting in health access deserts just as we have food deserts

Or biggest contractor Walmart style abuses of the suppliers of services

Our nation needs 30% more revenue over the cost of delivering primary care – because it is what is required to rebuild primary care clinicians and teams and because the investors that could expand primary care have non-primary care and other investments that they can choose that yield 30% or more.

Also the graduates of primary care training have higher pay and better support by not choosing primary care positions.

Our nation needs reimbursements that are sufficient by design, not another 30 years of special programs that are easy targets for narrow minded politicians with their even more narrow minded awareness of health care for most of those they are supposed to “serve”

Our nation needs a pure strain of family practice positions filled by MD, DO, NP, and PA – not training years, barriers, and declines that result in 8 – 25% family practice. Family practice positions filled are the multiple times solution for all most needed workforce. This also requires the financial support to keep such graduates in primary care and where needed – the opposite of current designs.